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FORM NO. (41 <br />wags <br />WELL CONSTRUCTION AND TEST REPORT <br />STATE OF COLORADO. OFFICE OF THE STATE ENGINEER <br />1313 Shewaer SL. Rmom Ste. Omar. CO 00203 <br />Phew - hde (303)1101-311117 Ills (301 MS 7651 <br />Fat CUM MOM M badle arw.lralsr.mlmmas <br />Far Odom Use Or, <br />_ <br />I. WELL PrR m esuu BNR 28 to <br />2. WELL OWNER INFORMATION <br />NAME OF WELOWER: L3 3 L C L1.0 <br />MA JUNG ADDRESS: P.0 Q e It 11 <br />CITY: NO lir STATE 2IP CODE: A I7IL, <br />TCLEPI IOIE NIABER ( I - <br />3. WELL LOCATION AS DRILLED: M iu. 5W 14 see. ZS • Tim). /9 ❑ Nor 0 S. Rep 711 ❑ E 010 W <br />DISTANCFS FROM SEC. LINES: /ete8 R from O N at 0 S sedan Ina sad /•3 L S. from 0 E or 0 W melon Saw. <br />, <br />SUBDIVISION: LOT . BLOCK _ FM.ING (UNR) <br />Dana's Wag Da <br />Optional GPS Localism GPS Unit must use the bNowig magic Formal mud be UTM. Urits <br />EasRig "" <br />O <br />must be abbrs. Dahtm must be NAOSA Unit must be set b Ow N. O Zone 12 or Zane 13 <br />STREET ADDRESS AT WELL LOCATION: Nslhkng YL4 3 S7 7 <br />4. GROUND SURFACE ELEVATION teat DRILLING METHOD A I r R.4aar <br />DATE COMPLETED you 2 c Inng TOTAL DEPTH 06 bet DEPTH COMPLETED CIO Net <br />S. GEOLOGIC LOG: <br />IL HOLE DIAM (h.) From no To Al_ <br />Depth <br />Type <br />Grain Size <br />Color <br />Wider Loc. <br />9 . Z O Z. 0 <br />Q -a <br />Sea&Linn <br />.? ta a <br />Lt Int <br />1. 3 to . <br />B — NZ <br />.12 - -:-.1i--- <br />Ce I k_s <br />Wi l <br />�e 4e> <br />uft <br />Gr e4 <br />Ala>! . <br />_ <br />7. PLAIN CASING: <br />00 (hi) �KM Vial Sta. (in) From (It) To (S)) <br />B 0 <br />4 Satmb <br />A - 7 <br />- ( <br />�wi.1dPr <br />• is � <br />%1srk <br />4. <br />• .. <br />_Lill _JAL. _ii___ <br />.• <br />.. <br />PERFORATED CASING: Sensn Slot Size (Mr. • 03 0 <br />Lux_ „ n i t 3_ o� <br />_sled _ _ _ <br />a. FILTER PACK <br />Maeda <br />11. PACKER PLACEMENT: <br />Type <br />Size <br />Naval <br />-96 <br />IL GROUTING RECORD <br />Amount Density Interval liarr ro nant <br />Maeda a Am � -��� <br />• <br />Remarks <br />2 0 <br />_Asti_ _Asti_ ... <br />11. DISINFECTION: Tow If Ti-i I /UM Used 2 0 Z <br />12. WELL TEST DATA: 0 Check boa i Teel Date Is subm3lsd on Fong Number (BATS 38 Supplamenld Wall Test <br />TESTING METHOD Air ISM Z OyaredIst <br />Static Level SO a. Dal /Ties meuurat: 4- 7 S -o CI PmduWlon Rale 2-0 gem. <br />Pumping Level 70 N. OaMMine measured 11- 7 S - o q Test Length (Iw.) / . <br />Ramis: <br />13. I here red the atMemrn4 aide Iwda sad knew In carrels lrreol. sad Srq awing a ma Ina adNe. Thin doomed la signal ant angled in <br />madam od a Rae 17A Mae Way NM CsMmden Rules. 2 CCR 41124. pee She M a demean( ad maim _Lie _ i a vltesson M <br />swam 2741- 101(1*). C.R.S.. and is ma+lr+le by than w a MOO adios prsewaa a are oarradn9:sense 1 <br />Company Nana <br />ASAP Well Drillint. Inc. <br />I Phone: <br />I 171 ) Sig 41M <br />License Number. <br />81 <br />MaikgAddreu P.O. Box 1718. Buena . CO 81211 <br />fists <br />Sigmas.: Prim Name and TNs <br />56 I. - Shawn L. Stake. President ____ <br />Oslo <br />1 1-Z1- 10 <br />10 <br />